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Getting Better: Improving Health System Outcomes in Europe and Central Asia
Recent narratives concerned with the study of economic growth offer potential lessons for developing a health reform agenda. The Commission on Growth and Development (2008), which was tasked with taking stock of the state of knowledge on economic growth with a view toward deriving policy implications, arrived at the conclusion that it could propose “ingredients” but not “recipes.” That is, it could identify certain common characteristics of countries with a strong track record of growth but not a fully articulated growth strategy (which would require specifying the quantities and sequencing of various measures), because “no single recipe exists.” Moreover, the commission could not say if its list of ingredients is sufficient or whether they are all necessary. It was also believed that the appropriate model changes over time. The five main ingredients of economic growth identified by the Growth Commission based on success stories of the past were the following: (1) they fully exploited the world economy; (2) they let markets allocate resources; (3) they mustered high rates of saving and investment; (4) they maintained macroeconomic stability; and (5) they had committed, credible, and capable governments. What, then, are the ingredients of successful health systems? Transposing the approach of the Growth Commission to the health reform arena, this section builds on the stock-taking exercise above and attempts to identify the most important inputs to health system reform. It identifies five key ingredients for health reform.
Three Ingredients for Accountable Health Systems: Payment, Autonomy, and Information The first three ingredients of successful health systems that we identify here are as follows: (1) some element of activity-based payment; (2) provider autonomy; and (3) information for decision making. Before we describe each in turn, it is worth emphasizing from the outset that the overriding theme linking all three is accountability. Later on, we also highlight two additional ingredients: adequate risk pooling and leadership commitment. The first ingredient is some degree of activity-based reimbursement, or “payment follows the patient.” For primary care, activitybased reimbursement means some use of fee-for-service methods, even if only partially in the form of a mixed system with other approaches. It could also take the form of a pay-for-performance scheme. An important complement to activity-based payment is patient choice, allowing the population to “vote with its feet” away from low-quality providers in favor of better ones. The antithesis